OHSU StudentSpeak » Anushka Shenoyhttp://www.ohsu.edu/blogs/studentspeak
Who better than the students to describe what being a student at OHSU is all about?Wed, 14 Feb 2018 18:26:28 +0000en-UShourly1http://wordpress.org/?v=4.2.19Tomorrow’s lessonshttp://www.ohsu.edu/blogs/studentspeak/2015/08/05/tomorrows-lessons/
http://www.ohsu.edu/blogs/studentspeak/2015/08/05/tomorrows-lessons/#commentsWed, 05 Aug 2015 23:14:44 +0000http://www.ohsu.edu/blogs/studentspeak/?p=7793Read More]]>

Dear ——–,

You were my patient for four days. On the first day, we treated your many diseases. On the second day, we removed all but comfort measures. When I arrive at the hospital tomorrow, you will not be there. My boyfriend worries about me tonight, as you are my first patient to die. I am surprised to tell him that I feel only gratitude for you.

Thank you for being my first patient to die. Thank you for being old and frail. Thank you for displaying clearly and eloquently, despite an illness that has robbed you of speech, your desire to move on. Thank you for smiling at me on day one, for asking my name, introducing yourself. Thank you for clutching my hand on days two, three and four when I came to wet your lips and ask you if you were in pain. Thank you for not being in too much pain. Thank you for having a caring family who loves you but does not depend upon you, who will have each other to share memories and grief on days five, six, seven.

I am so sad that you will die tonight. I am sad for your children, who have hovered around you over the past four days, and for your spouse, whom you cared for with love and kindness. I am so sad that we don’t get to unpack your ailments together, one by one, stating them in a problem list and labeling them – acute, worsening, improving, resolved. I don’t know how to write a discharge summary for you. I can’t discharge you from my mind: your kind eyes, your thin, frail skin, your erratic, persistent breath, your fervent dignity in the face of your body’s determined deterioration. Thank you for sharing this part of your life with me. Thank you for sharing your death with me. Thank you for your teachings over the past four days and for the lessons that await me tomorrow. Thank you.

Note: If you’d like to get involved with HCEW, please contact Taryn Hansen (cansler@ohsu.edu)

First and second year medical students spend a lot of time in classrooms. Despite electives, preceptor experiences and volunteer commitments outside of schoolwork, most of us spend more time than we would like listening to lectures, studying and proving our knowledge on standardized tests. During Health Care Equity Week (April 20 – 26), students from various disciplines are attempting to extend our classroom walls. During the week, we will have various lunchtime talks from local experts in healthcare disparities and efforts to provide affordable, quality healthcare for all. On Sunday, April 26, medical, dental, nursing and pharmacy students will set up camp in a parking garage in Bryant Park to provide health care for Portland’s homeless, hurting and underserved population.

One day of foot cleaning, blood pressure screenings and ten-minute doctor’s visits will not fix many problems, but we are optimistic that we can raise public awareness of health disparities, raise our own awareness and provide some much-needed services. We are studying medicine in the context of significant changes to our health care system, but it is important for us to remember, and see, those whose situations will not change through the Affordable Care Act – those who are still vulnerable due to their living situation, immigration status or reticence to engage in the traditional health care system. Last year at this event, a physician and I diagnosed a non-English speaking man with strep throat and the pharmacy students were able to provide a course of antibiotics. The man admitted to me that he was unlikely to attend his follow-up appointment with a local, low-cost provider because of his immigration status. This encounter taught me more about health care in Oregon than a course of lectures about the Affordable Care Act. We didn’t solve that man’s problems – where did he sleep that night? Did his symptoms resolve? Is he able to work in this country? – but perhaps we helped a little. That learning in and of itself is valuable; we can never solve a patient’s problems, but we can continue learning and changing the small things we can control.

On Sunday, April 26 we will try to change many small things, through diabetic foot exams, vision and hearing checks and other health care that we can provide for six hours in a parking lot. We also have referrals to primary care and specialty clinics in the community and can hand out select medications to those that need it. Finally, we will have coupons for a meal at Sisters of the Road Café for our patients. Health Care Equity Week might not solve all the problems, but hopefully it will enlighten some students and brighten some patients’ days.

Larissa Guran wrote last month about our “Leadership, Education, and Structural Competency” course at OHSU, and I would like to add to her thoughts. As a reminder, we developed the course to learn facilitative leadership skills, strengthen our understanding of social determinants of health, and develop and facilitate five small-group sessions about structural competency for the new MS1 curriculum. After a session on implicit bias, we introduced the concept of taking an “Affective Time Out” to reflect on the emotional, mental, and intellectual preconceptions we bring to each patient encounter. As we approach our final MS1 session, I wanted to take my own “time out” of sorts and reflect on this experience.

Here’s what I’ve learned:

Collaborative learning works if it’s authentic and student-driven. For this class, three to four students developed the curriculum for each MS1 session, and we workshopped each session for over two hours as a large group. I learned how best to engage with my peers on sensitive issues; for example, we had a somewhat tense discussion during one workshop after which a classmate provided candid feedback about my communication style and body language.

]]>http://www.ohsu.edu/blogs/studentspeak/2015/04/07/students-teaching-students-passion-collaboration-innovation/feed/0Understanding the symbolic power of my white coat, part IIhttp://www.ohsu.edu/blogs/studentspeak/2015/01/27/understanding-the-symbolic-power-of-my-white-coat-part-ii/
http://www.ohsu.edu/blogs/studentspeak/2015/01/27/understanding-the-symbolic-power-of-my-white-coat-part-ii/#commentsTue, 27 Jan 2015 20:17:44 +0000http://www.ohsu.edu/blogs/studentspeak/?p=7108Read More]]>A few weeks ago, I wrote a post about deciding whether or not to wear my white coat at a protest about recent events in Ferguson, MO, and Staten Island, examples of the more widespread problem of violence against communities of color in this country. As I’ve considered these events and their implications, I find I have a bit more to say.

On International Human Rights Day (December 10th), 20-30 OHSU students lay down in the atrium of the CLSB for four minutes, representing the four hours that the teenaged, unarmed Michael Brown lay on the pavement after being shot by a police officer. Unlike Michael Brown, we were not alone. Students from over 70 medical schools participated in this symbolic gesture and the hash tag #whitecoats4blacklives was trending on Facebook by the end of the day (you will not find OHSU’s name on the list of schools participating, as students were instructed to cover the logo on our white coats and not to affiliate ourselves with the university*). I participated in this gesture with tears in my eyes and hope in my heart. Just a week before, I wondered about the validity of wearing my white coat to a public protest – why was I OK with participating in a national movement that prominently featured this symbol?

I realized that I consider structural violence a public health issue. Put more simply, I think that when young black men unnecessarily are killed, this is a public health issue, just like preventable deaths from suicides and car accidents are public health issues. I also consider it a human rights issue.

I understand that there is often disagreement about what constitutes a public health or human rights issue. For example, we differ broadly on what types of health services we think should be provided by the government in the interest of public health. I am not asking every medical student and doctor to agree, but I am also unwilling to accept the claim that this issue, however contentious, is exclusively personal or political. Doctors do not become blank slates when we put our white coats on – we are living, feeling interpreters of the Oath of Geneva’s mandate to “consecrate [our lives] to the service of humanity.” Per my interpretation of this Oath, if I see an egregious loss of human life, I must speak out against it not just as a citizen, but as a physician in training.

Just as doctors who crusade for seatbelt education aren’t anti-driver, I’m not anti-police. I respect our first responders and cannot imagine a society without them. I think that doctors can, and do, take public positions (for vaccines, against cigarette smoking) without compromising our integrity; that we can, like the Oath of Geneva instructs, “not permit considerations of age, disease, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between [our] duty and [our] patient[s].”

I have learned a great deal over the past few weeks. I have learned that when I write about things that anger and sadden me, I feel more empowered. I have learned that many of my colleagues feel angered and saddened by the same things that anger and sadden me, and that we can seek solace and inspiration in each other. I have learned that for me, structural violence is a human rights and public health issue. I have learned that some in my profession see contentious issues as those to be avoided, but that I do not. I have found that productive dialogue around scary topics is scary, but helpful. Finally, as we lay on the ground in the CLSB, I learned that, as the Oath of Geneva says, my colleagues are my brothers and sisters.

Thank you for reading this piece and the previous. As you can tell, I will remember the last few months of 2014 as a time when my social conscience was shaken awake despite the pressing academic demands of medical school. I hope that I keep paying attention to and talking about human rights and public health issues over the course of my career, and I encourage my peers to do so as well, even if your issues are different from my own. I think that’s part of the job description.

* OHSU understands the white coat is emblematic of the medical profession, however, as a public entity, OHSU cannot endorse a political act. OHSU welcomes robust debate about important issues and supports individual rights to free speech and values its active, engaged student body.

Like many Americans, I have been confused, surprised, angered and saddened (often all at the same time) by recent events in Ferguson, Cleveland, New York and too many other cities across our country. More specifically, I cried when I learned of the grand jury’s failure to indict Darren Wilson in the murder of Michael Brown, an unarmed, black teenager in Ferguson, Missouri.

In response, for the first time ever, I decided to attend a rally and march in Portland protesting these events and the underlying challenges they present for our society. For me, this decision also required me to consider for the first time the role of my white coat in making a statement at the rally. Would I attend the rally as a future physician, a citizen or some combination of both? And what is the significance of my choice?

Our white coats, short though they still are, are symbols of our profession. Our profession is one held up by many in this country as one of educated, responsible, kind individuals, and we are conferred rights, privileges and responsibilities by virtue of our engagement in this profession (much like, some might comment, police officers). We were told so at our white coat ceremony, when we stood and took the Oath of Geneva for the first time. We are told so when we are held to the highest standards of professionalism, defined by our profession and our academic institution.

Can I, then, represent my profession, not just my person, at this protest? I protest what happened in Ferguson as an American, as a person of color, as a citizen, as a civilian and as a human being. Do I also protest it as a medical student?

I cannot easily think of another profession (again, the police force comes to mind here) whose trainees wear such an easily recognizable marker. Am I, a second-year student, posturing when I wear my white coat to this protest, or by leaving it in my locker, am I eschewing an important responsibility?

I already find myself, when talking to friends and family, couching what I know to be personal beliefs as separate from my day life as a medical student: “We didn’t learn this in school, but I think that drinking hot tea with turmeric and honey bolsters my immune system…” At the same time, my title as “medical student” feels more central to my identity than my previous professional titles (not to mention that my title on wedding invitations and email coupons, both decidedly personal, will change in a few years).

Simultaneously, I feel more responsibility to conduct myself appropriately in the public arena then I did before medical school and feel that it is even more important to be engaged and knowledgeable on social issues. In fact, maybe my decision to attend my first protest is in part because of my experiences over the last year as a medical student. And yet, and yet, I am not sure that I can wear my white coat at that protest – I am not sure I have passed some sort of invisible test, or earned my merit badge, quite yet. Is that unnecessary, crippling self doubt or healthy humility?

To conclude – it turned out that my white coat was at the dry cleaner’s and I couldn’t get it back in time for the protests, so I went in my raincoat, my OHSU badge tucked in my pocket as we were instructed* not to display the university logo at the protest. I was proud to stand by my friend wearing his coat, a peace sign covering the identifying logo and my friend who chose not to wear her coat. I think I would have been proud of myself for wearing my coat to the protest, but I am not sure I would have had the courage or tenacity to. At least not yet.

***

* OHSU understands the white coat is emblematic of the medical profession, however, as a public entity, OHSU cannot endorse a political act. OHSU welcomes robust debate about important issues and supports individual rights to free speech and values its active, engaged study body.

]]>http://www.ohsu.edu/blogs/studentspeak/2014/12/12/understanding-the-symbolic-power-of-my-white-coat/feed/0What do you think she meant?http://www.ohsu.edu/blogs/studentspeak/2014/05/20/what-do-you-think-she-meant/
http://www.ohsu.edu/blogs/studentspeak/2014/05/20/what-do-you-think-she-meant/#commentsTue, 20 May 2014 21:52:28 +0000http://www.ohsu.edu/blogs/studentspeak/?p=6178Read More]]>

On Monday morning, I was sick. I also had an immunology exam at 8am. Bristling from the cruel irony, I stopped at a Starbucks near the highway in yoga pants, a T-shirt, and my OHSU badge at about 7:30am. Red-faced from sneezing all night and baggy-eyed from attempting to study in that condition, I ordered a black coffee and waited miserably while my cup was filled. As I stood there, pathetic, a well-dressed, middle-aged woman approached me.

“What do you do at OHSU?” she asked, standing so close to me that I was acutely worried about spreading my germs. I told her that I was a medical student, and that I had an exam in just twenty minutes. She wished me luck. The barista handed me my coffee and I smiled politely and turned to leave, but the woman stopped me.

“So you’re going to be a doctor?” she asked. I nodded. “Can I tell you something?” She looked directly into my eyes. Again, I nodded. “I have spent a lot of time on the hill over the past few years with various friends and family who have been sick – and I want you to know that the most important thing is that patients trust their doctors.” I smiled in agreement and said that I often thought about my future patients when I studied. But she shook her head and touched my (no doubt feverish) arm. “I don’t mean trust their knowledge of, you know, bacteria and science…” (I had told her I had an immunology exam) “… I mean, that they trust their doctors as people. That they feel that their doctors are reasonable. I see doctors talking in the hallway, chatting with each other… patients pay attention to that. They want their doctors to have good judgment.”

Honestly, I didn’t really know what she meant – but she seemed so focused, so earnest, that I promised her I would share her comments with my peers. And so I am sharing them now, and hoping that through expression, I will begin to understand her more fully. Did she mean that patients want doctors to have a strong moral compass? That we would make wise, mindful decisions if we were in their shoes? Simply that we prescribe the most efficacious, least harmful treatment? That when we speak about or with our patients, in hallways, elevators, or patient rooms, that we show respect and humility? I trust my judgment when it comes to my own life, and the advice I give my friends and family – is this the same judgment I will soon use to counsel patients? Is this the judgment that she means?

As I said, I didn’t have time to ask her what she meant, or to ask her to share her stories of good and not so good doctors on the hill. I had to go take an immunology exam, to test my knowledge of interferons and antibodies and inflammation and infection. I don’t think that the judgment that she was talking about will ever be measured on a multiple choice test, but I hope that if I don’t have it already, I develop it over the (seemingly endless) years of training in front of me. What do you think she meant?

For two harrowing weeks, I experienced the health care system from the other side. My grandmother, visiting from India, had a fall that turned into an emergency room visit that turned into an electrolyte imbalance that turned into an idiopathic neurological problem that turned into a coma that turned into her unexpected death. Less than two weeks after what seemed like a routine fall, she died.

The ten days my grandmother spent in the hospital confused all of us. One night, she got two CT scans and an MRI (she was under-insured and no one gave us a straight answer about billing). She saw a doctor roughly every twelve hours, and we relied mostly on her nurses for information about her health and schedule. We got excited about an occupational therapist who never showed up. A young, probably exhausted resident ordered an extensive procedure without explaining it, her attending canceled it, the specialist ordered it again, and finally, it was not performed. We had to remind her health care teams to change her, move her, give her medications, and even take the necessary labs. My father and I ensured that one of us was always in the room, but we were both moved almost to tears on several occasions by the difficult of receiving not only care but also basic information about her status.

A year ago, I would have cursed the hospital for this treatment. Now, I understand how tired the resident must have been, and I know the feeling of waiting for your attending, worried about asking a stupid question. I know that a hospitalist can see two dozen patients a day. I see how hard nurses work. I vaguely understand the process of making a differential diagnosis, and I know that when a pattern is not easily recognizable, the process can be arduous, didactic, and, yes, expensive.

What if my grandmother were a young woman with children to care for? What if her son were not able to take two weeks off of work to be with her almost full time? What if she did not have physicians in her family who could use back channels to advocate for her care? Even with family friends with privileges at the hospital, her son by her side, and a granddaughter in medical school, my grandmother languished in the hospital for a week before leaving without a diagnosis. It’s not just the “others,” the “healthcare illiterate,” who are scared and confused in hospitals. My father is an educated, highly successful man, and he was flummoxed by the doctors’ schedules and recommendations. I am a medical student, and I felt helpless every moment I was there.

The hospital, where we gossip, laugh, share stories about our weekend trysts, is not a terrifying place “for other people.” It is a terrifying place for anyone who is there because they are sick, or someone they love is sick. The difference between our patients and ourselves is nothing more than circumstance.

I hope that our system evolves so that an unexpected hospital visit does not have the possibility to bankrupt a family. I hope that we are able to incentivize bright, hard working people like the nurses I met to need the growing needs of our health care system. I hope that medical research continues to expand the edges of our knowledge, laid so painfully bare by this case. Most importantly, I hope that my peers and I remember that we are on our side of the hospital bed not because we are special, not because we are intrinsically better or even different than those we care for, but because we are a little bit luckier. I hope we remember to care for our patients and their families as though they are our own, because not so infrequently, they are.

I want to write about the Donor Memorial Service that we had for the men and women who donated their bodies to further our medical education. I want to write about the sadness and grief we shared, the inspiring families and loved ones who trekked up the hill for the service, and my amazing peers who planned the entire event, greeted our guests in subzero weather, presented thoughtful speeches and musical performances, and stayed late on a Friday evening to clean up after the event. I don’t think I can do the event justice, even in my own head. Instead, I will share with you the speech that I shared at the service. It follows.

Hello. I would like to welcome to this community. Thank you for being here. I am so, so sorry for your loss.

My name is Anushka. I grew up in Portland, and I am a first year medical student. On August 16th, my colleagues and I walked across this stage one by one, donning the white coats for the very first time. In four years, we hope to walk across this stage as doctors.

These ceremonies do not come without sacrifices.

Our families make difficult financial choices so that we can spend our time here. Our children see less of us. Our partners absorb our stresses, guard our fears, and hold us after long, tiring days. They reorganize their lives around our sometimes all-consuming goals. We will walk across this stage again because of their commitment. We will also walk across this stage because of you. Most importantly, we will walk across this stage because of those we remember today.

The gift that your loved ones, and you, gave us, the commitment that you all made to our education, is the most fundamental, the bravest, and the most important investment anyone has made in our futures. I have never, and likely never will, receive a gift more personal or more significant than this.

We cannot satisfactorily acknowledge the magnitude of this sacrifice, but we can promise you this: we promise to see this gift, this act of faith, in every patient. We promise to treat our patients and their families with the respect and gratitude that we feel towards you and your loved ones. We promise to remember, acknowledge, and continually be humbled by their role in and commitment to our lives. Steve Prefontaine said, probably not too far from here, that “To give anything less than your best is to sacrifice the gift.” We promise to give our best and honor the gift. We will be the best listeners, the best healers, the best doctors that we possibly can be because of, and in memory of, your loved ones.

On that day in August, my classmates and I embarked on an extraordinary journey together. After a difficult test, a friend reflected that “Looking around during the exam…I can’t help but think about how lucky and fortunate I am to be in this position.” I agree with him, and I know that the journey will continue to amaze, challenge, and overwhelm us. I also know that the journeys we have embarked on by donning these white coats are nothing, nothing, nothing compared to the journeys you took with your loved ones, the moments you celebrated, the challenges you overcame, the memories and grief that you are left with. I want you to know that we consider your loved ones an inexorable and unforgettable part of our journeys. We remember them, we grew and changed because of them, and we miss them, too.

In many professions, “difference of opinion” is code for “all out conflict” or “war.” When you “agree to disagree,” you are often agreeing to part ways. This is the case in the political arena, where campaigns, interest groups, and even research organizations are often partisan, and even in the corporate world, where Boards of Directors and executives are chosen because of a shared vision of leadership. In our medical school class, we often agree to disagree, and our differences of opinion lead to thought-provoking and lively conversations. The differences of opinion I have with my classmates will make me a better physician.

A few weeks ago, we discussed motivation interviewing in our clinical medicine class. As a classmate and I walked out of Richard Jones Hall, I expressed an opinion on the lecture, and was surprised that he passionately and coherently expressed a different point of view. Should doctors confront their patients about harmful behaviors? What are the risks of doing so, and what should the practical and ethical considerations be? As we talked, several classmates joined us. Some contributed their perspectives, and many just listened. After a recent exam, a few of us discussed the best ways for scholarship monies to be divided amongst medical students. Should financial aid be merit based, need based, both, or neither? What other factors should be considered? Not only were we able to agree to disagree over this potentially contentious issue, the conversation continued within our class and with the administration. In fact, the administration has joined our conversation several times, when members of our class expressed strong opinions about our curriculum and its evolution. What say should we have in the changes to our curriculum? How accountable is the administration to its students?

Last week at a student-run clinic, a resident and I visited a patient together. Her case seemed straightforward and our encounter was brief. Later, I asked the resident a few follow up questions about the patient’s care. I worried I might sound silly, but I had a few lingering concerns. The resident carefully explained the case to me, and during our conversation, we realized that we might have missed something important. We reviewed her chart, discussed it with the attending physician, and ordered more labs and a comprehensive follow up. Had I not been empowered to voice my concerns, or had the resident not welcomed an open conversation, the patient may not have received the best quality care. When my classmates and I vehemently disagree one moment, then joke around or bemoan our workload, we practice skills of openness, humility, and professional discourse that will lead to better clinical outcomes.

If people glance at photographs of our class, they could easily conclude that we are not very “diverse.” In many ways, they would be right. This paucity of diversity was a real concern for me when I decided to join this community, and it still is as a community member. However, I must say that I am pleasantly surprised by the diversity of background, opinion, belief, and knowledge bases represented in my class, and more importantly, by the courage and eloquence my peers demonstrate by expressing their opinions vocally and articulately. We put pressure on our administration, on our teachers, and on each other. I think that this will make us better doctors and better people, and I am proud to be part of a community that encourages disagreement and discourse.

“It’s just, like, acting like a human.” A fellow first year medical student eloquently summarized our Principles of Clinical Medicine class. The “techniques” we practice seem basic on first glance: Express the patient’s Chief Complaint in their own words. Ask the patient to describe the Onset of his or her symptom, what Provokes or Palliates it, it’s Quality, and so on and so forth to the tune of a convenient acronym. Explore socioeconomic or psychological drivers of a patient’s ailments by asking how her life is going, what affects her the most, and how she is coping. Always, always, even when the acronym does not explicitly ask, show Empathy. Also, wash your hands and clean your stethoscope between patients.

As an altruistic human being who has chosen the Noble Path of medicine, practicing these “common sense” communication skills should be easy for me. It’s just, like, acting like a human.

Two days before our first GIE exam, tensions were notably high. I found myself snapping at a lab partner, interrupting her question to ensure that we finished our dissection. I was terse with my boyfriend: when he expressed a long-standing and perfectly valid concern about our relationship, I burst into tears and sidetracked the conversation with my own issues. Strangely, the “basic human skills” taught in PCM slipped to the wayside when “medical school emotions” turned on high. I did not ask my partner when the Onset of his frustration was, or how I could Palliate it. When a student asked one too many questions during a review, I did not reflect on her psychological state. I did not repeat my lab partner’s Chief Complaint (or question) back to her in her own words, ensuring that it was answered comprehensively. I showed a marked lack of Empathy for fellow drivers on 26W.

Many aspects of medical school training bring out our humanity. Before mastering the brachial plexus, we become guardians of patients’ secrets, fears, and confessions. We spend hours examining our donor bodies, inevitably pausing and wondering about their lives and their deaths. We share our often deeply personal motivations for choosing this path over a hurried coffee or a more relaxed beer. However, medical school can be deeply dehumanizing. Though we maintain a patient focus in our clinical encounters, for many of us, our personal lives become more self-centered. We spend more time studying, paying attention to our own habits, memory, and sleep cycle, perhaps less time actively listening to our friends and colleagues and, perhaps, even less time demonstrating Empathy to the classmates, professors, and loved ones supporting us through this journey. Some of us neglect long standing rituals, from a daily run to hours of television on Saturday morning, to achieve our academic goals. So though it’s impossibly cheesy, I purport that maybe the practice of being human, like memorizing abdominal innervations, takes practice. I purport that we need to pause to ask ourselves how we are coping, which challenges affect us the most, and how we are handling medical school, with its unprecedented demands on our hearts and minds. Even if we didn’t need to before, we now need to practice seeing the world from other perspectives, whether or not we’re wearing our white coats. Maybe demonstrating Empathy, like understanding the autonomic nervous system, is a more daunting task than one would expect. For the sake of our patients, families, colleagues, and future selves, I hope we are all up to the challenge.